Análise dos registros de curativos em prontuários de um hospital de ensino do Estado de Goiás
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2016-06-21
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Universidade Federal de Goiás
Resumo
Health records are important for keeping effective communication among all professionals
involved in the process of taking care as well as for legitimating the team actions in the face
of patients and families. The records must be clear and objective because they are sources of
information for judicial, research, teaching, billing and auditing issues. This study has an
objective to analyze the records of procedures of Level II Curative in medical records of
hospitalized patients, from the nurses’ perspective, before and after the pedagogical
intervention, in a Brazilian teaching hospital in the Midwest region. It was a descriptive study
with both qualitative and quantitative research and was developed in many stages. The first
stage included the nurses’ profiles and the identification of the main reasons why the nursing
actions were not recorded. The second stage was the analysis of the records before and after
the pedagogical action, which was the third stage. At last, the nurses were interviewed about
their perception of the importance of the records for billing. It was observed among the sample
of nurses the predominance of women (87,2%), post-graduated (82,1%) and statuary civil
servants (80,4%). Even though 53,6% of the nurses said that they do not have double
employment relationships, 46,4% said they do. The nurses said that it was not possible to
record the procedures due to lack of time (50%), work overload (20%), lack of human
resources and access to the records (12,5%), interruptions and lack of guidance (2,5%). The
objective of the intervention was to discuss the importance of health records, and specially,
in relation to the level II curative. 45,2% of the nurses of this institution took part in this
event. In the analysis of the records, before and after the intervention, it was possible to
observe the increase of the records of the curatives (82,3%), the detailing of the quantity of
curatives per patient (69,9%), the classification of the wounds (63,5%), the description of the
materials used in the procedures (67,3%), and also the scheduling (74%) and the checking
(71,4%). The data shows that the quantity of material used maintained still. However, there
was a rise of curative prescription by the nurses (79,4%) and a fall of curative prescription by
the doctors (18,3%). It was also possible to observe that the performed and not prescribed procedures or prescribed and not verified procedures, in both cases, were not billed.
Nevertheless, the hospital overturn related to this procedure has an increase, from July 2015.
The interviews with the nurses showed that they take the responsibility in the treatment of
wounds for themselves. However, it is necessary to standardize the prescriptions and the
evolutions of the procedure. The complete record of this intervention is important to safeguard
the institution in case of auditing. In conclusion, nurses have an important role in recording
the wound treatment. The obligation of recording should be reinforced due to the quality of
the service and the profession´s visibility as well as for a better material and input control and
billing.
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LEMOS, L. F. Análise dos registros de curativos em prontuários de um hospital de ensino do Estado de Goiás. 2016. 109 f. Tese (Doutorado em Enfermagem) - Universidade Federal de Goiás, Goiânia, 2016.